Integrating exercise interventions into routine care for mental illness and cancer : An implementation science approach

Exercise has been established as an effective intervention that can improve health outcomes in people living with a non-communicable disease (NCD), including mental illness and cancer. Despite the evidence, exercise is not routinely integrated into the treatment of most NCDs. This phenomenon is described as the research-to-practice gap with implementation science seeking to increase the uptake of evidence-based interventions (EBIs), such as exercise, in practice. Multiple factors and processes contribute to the suboptimal use of EBIs in practice. This includes the lack of formative approaches to establish research evidence that is relevant for implementation and scientific methods that explain EBI adoption, implementation, and sustainment. This thesis applies an implementation science approach to explore how exercise EBIs can be integrated into routine healthcare to treat NCDs. This is explored in two NCDs, mental illness and cancer, and through the two following sub-aims: • Conduct novel evidence synthesis for mental illness and cancer to understand how different synthesis methods can support improved implementation in practice. • Explore how healthcare organisations have successfully implemented exercise EBIs within the routine practice for treating mental illness and cancer. To address the first sub-aim, unique approaches were applied to two systematic reviews that were conducted in mental illness and cancer. For the first systematic review, a meta-review design was used to synthesise the evidence on the effectiveness of exercise EBIs for mental illness. effectiveness was defined in clinically useful terms including the anticipated health benefits, safety and cost of exercise EBIs. Although positive effects on health outcomes (i.e., symptoms of mental illness, quality of life, and physical health outcomes) were reported in the majority of reviews, limited safety information and no cost data were identified. For the second systematic review, efficacy studies were excluded to investigate the real-world implementation outcomes of exercise EBIs for cancer care. Implementation outcomes were aligned with Proctor and colleagues’ Implementation Outcomes Framework (IOF), and the review revealed that the most common implementation outcomes assessed were adoption and feasibility. Penetration and sustainability were infrequently measured, and implementation fidelity was difficult to establish because exercise protocols were poorly reported. In sum, the unique methods used in the two systematic reviews enabled the synthesis of broad and contextually relevant information valuable for implementation practice. The research gaps identified suggest that there is significant scope to produce more practice-relevant evidence. To address some of these gaps and the second sub-aim of this thesis, two implementation studies that explored how healthcare organisations have successfully implemented exercise EBI’s in mental health and cancer were conducted. For both studies, a case study design and theoretically-informed approach were used to develop an explanation for the implementation process that included the identification of determinants, implementation strategies, and implementation outcomes. Four data sources informed the studies: semi-structured interviews, document review, observations, and administering the Program Sustainability Assessment Tool (PSAT). Framework analysis was applied, and a theory-informed logic model was developed. Linking implementation science frameworks through the logic model elucidated the causal pathways of implementation. Second, the methods facilitated synthesis across sites to support generalisable knowledge. The first implementation study evaluated an exercise EBI implemented within a youth mental healthcare service. Over 40 determinants that influenced implementation of exercise EBIs and a similar number of implementation strategies were identified. Several activities aided implementation, including the creation of a new clinical team and the auditing and provision of feedback on physical healthcare practices (including exercise). Exercise acceptability was high, and many strengths (identified via the PSAT) contributed to EBI sustainability. However, implementation fidelity was challenging to establish, and penetration was low. The second implementation study was a multiple case study on the implementation of exercise EBIs across three cancer care settings. Across the sites, 18 determinants and 22 implementation strategies were consistent. Sixteen determinants, 24 implementation strategies, and implementation outcomes differed across the sites. Via the commonalities, 11 common causal pathways were developed, wherein the mechanisms theorised to support implementation include: 1) developing knowledge; 2) building skills and capability; 3) securing resources; 4) generating optimism and 5) simplified decision-making processes associated with exercise; 6) developing relationships (social and professional) and support for the workforce; 7) reinforcing positive outcomes; 8) developing capability to action plan through evaluations and 9) interactive learning; 10) aligning goals between the organisation and the EBI; and, 11) establishing a consumer-responsive service. These mechanisms represent transferable elements of the implementation process that can inform future implementation efforts. This thesis uses implementation science to increase our understanding of the evidence, factors, strategies and processes required to implement exercise EBIs in practice. Improved implementation knowledge will help shape healthcare so people living with a NCD can access evidence-based care, such as exercise

Developing an implementation research logic model : Using a multiple case study design to establish a worked exemplar

Background Implementation science frameworks explore, interpret, and evaluate different components of the implementation process. By using a program logic approach, implementation frameworks with different purposes can be combined to detail complex interactions. The Implementation Research Logic Model (IRLM) facilitates the development of causal pathways and mechanisms that enable implementation. Critical elements of the IRLM vary across different study designs, and its applicability to synthesizing findings across settings is also under-explored. The dual purpose of this study is to develop an IRLM from an implementation research study that used case study methodology and to demonstrate the utility of the IRLM to synthesize findings across case sites. Method The method used in the exemplar project and the alignment of the IRLM to case study methodology are described. Cases were purposely selected using replication logic and represent organizations that have embedded exercise in routine care for people with cancer or mental illness. Four data sources were selected: semi-structured interviews with purposely selected staff, organizational document review, observations, and a survey using the Program Sustainability Assessment Tool (PSAT). Framework analysis was used, and an IRLM was produced at each case site. Similar elements within the individual IRLM were identified, extracted, and re-produced to synthesize findings across sites and represent the generalized, cross-case findings. Results The IRLM was embedded within multiple stages of the study, including data collection, analysis, and reporting transparency. Between 33-44 determinants and 36-44 implementation strategies were identified at sites that informed individual IRLMs. An example of generalized findings describing “intervention adaptability” demonstrated similarities in determinant detail and mechanisms of implementation strategies across sites. However, different strategies were applied to address similar determinants. Dependent and bi-directional relationships operated along the causal pathway that influenced implementation outcomes. Conclusions Case study methods help address implementation research priorities, including developing causal pathways and mechanisms. Embedding the IRLM within the case study approach provided structure and added to the transparency and replicability of the study. Identifying the similar elements across sites helped synthesize findings and give a general explanation of the implementation process. Detailing the methods provides an example for replication that can build generalizable knowledge in implementation research

Implementation of physical activity interventions in a community-based youth mental healthcare service : A case study of context, strategies, and outcomes

Aims Physical activity interventions are recommended for community-based youth mental health services to prevent physical health disparities. Implementation is challenging, and studies focusing on the methods to achieve change are needed. This study aims to identify the context, implementation strategies, and implementation outcomes that illustrate how physical activity interventions were implemented within an early intervention service in Australia. Methods A theoretically informed case study was undertaken. Data from a community-based youth mental health service that delivers an early psychosis programme were collected between July and November 2020. Three data sources were accessed (1) interviews with service managers, mental health clinicians and exercise physiologists; (2) document review of organizational policies and procedures; and (3) survey using the Program Sustainability Assessment Tool. The implementation outcomes investigated were acceptability, fidelity, penetration, and sustainability. Framework analysis was used, and a logic model developed guided by an established template, to interpret findings. Results Forty-three contextual factors and 43 implementation strategies were identified. The data suggests that creating a new clinical team and auditing and feedback are critical for implementation. High levels of acceptability and sustainability were described, while fidelity of implementation was difficult to establish, and penetration was low. Conclusions The relationship between constructs suggests several mechanisms underpinned implementation. These include changing professional beliefs, establishing new organizational norms, augmenting existing work processes, and aligning physical activity with priorities of the mental healthcare system and existing work tasks. This case study provides direction for future health service planning of physical activity interventions in community-based youth mental health service

Health benefits, safety and cost of physical activity interventions for mental health conditions:A meta-review to inform translation efforts

Background Mental illness is a leading cause of the global burden of disease. Physical activity (PA) can improve physical and mental health outcomes for people with mental illness, yet routine implementation of PA within standard care remains ad-hoc. The reasons for this are unclear, although the dissonance between the evidence produced in research settings and that needed in real-world environments may be key. Purpose To explore the effectiveness of PA interventions as a treatment for mental illness. We synthesised past systematic reviews and meta-analyses. Methods We conducted a systematic review of reviews from database inception to 09/2017. Reviews were included that considered any mental health condition (diagnosed via standardised criteria) and where PA interventions were a stand-alone or adjunctive treatment. Effectiveness was defined as outcomes that are important in real-world healthcare (i.e. expected clinical outcomes, intervention safety and cost). Results From 4008 hits, 33 reviews (including 155 unique studies) were included and 32 reported that PA has a positive effect on at least one main outcome of interest (symptoms of mental illness, quality of life and/or physical health). There was inconsistent reporting of adverse events and no cost data was identified. The AMSTAR quality rating suggests inconsistencies in review quality. Conclusions The research agenda must expand to report on outcomes that can support evidence translation efforts (i.e. cost and adverse events). Without such a shift, research in PA and mental health may fail to achieve translation to routine care and may have limited impact on patient outcomes

Implementing Exercise in Healthcare Settings: The Potential of Implementation Science

Exercise is an efficacious therapy for many chronic diseases. Integrating efficacious evidence-based interventions (EBIs), such as exercise, into daily healthcare practice is a slow and complex pursuit. Implementation science seeks to understand and address this phenomenon by conducting studies about the methods used to promote the routine uptake of EBIs. The purpose of this article is to explore implementation science and a common conceptual framework in the discipline, the Consolidated Framework for Implementation Research (CFIR), as it applies to exercise EBI. We conclude by offering recommendations for future research that leverage implementation science priorities to highlight the potential of this research field for advancing the implementation of exercise EBI

Exercise interventions for people diagnosed with cancer : A systematic review of implementation outcomes

Purpose Exercise is efficacious for people living after a cancer diagnosis. However, implementation of exercise interventions in real-world settings is challenging. Implementation outcomes are defined as ‘the effects of deliberate and purposive actions to implement new treatments, practices, and services’. Measuring implementation outcomes is a practical way of evaluating implementation success. This systematic review explores the implementation outcomes of exercise interventions evaluated under real-world conditions for cancer care. Methods Using PRISMA guidelines, an electronic database search of Medline, PsycInfo, CINAHL, Web of Science, SportsDiscus, Scopus and Cochrane Central Registry of Controlled Trials was conducted for studies published between January 2000 and February 2020. The Moving through Cancer registry was hand searched. The Implementation Outcomes Framework guided data extraction. Inclusion criteria were adult populations with a cancer diagnosis. Efficacy studies were excluded. Results Thirty-seven articles that described 31 unique programs met the inclusion criteria. Implementation outcomes commonly evaluated were feasibility (unique programs n = 17, 54.8%) and adoption (unique programs n = 14, 45.2%). Interventions were typically delivered in the community (unique programs n = 17, 58.6%), in groups (unique programs n = 14, 48.3%) and supervised by a qualified health professional (unique programs n = 14, 48.3%). Implementation outcomes infrequently evaluated were penetration (unique programs n = 1, 3.2%) and sustainability (unique programs n = 1, 3.2%). Conclusions Exercise studies need to measure and evaluate implementation outcomes under real-world conditions. Robust measurement and reporting of implementation outcomes can help to identify what strategies are essential for successful implementation of exercise interventions. Implications for cancer survivors Understanding how exercise interventions can be successful implemented is important so that people living after a cancer diagnosis can derive the benefits of exercise

Self-reported physical activity levels of the 2017 Royal Australian and New Zealand College of Psychiatrists (RANZCP) conference delegates and their exercise referral practices

Background: Physical activity (PA) significantly improves physical health and clinical symptoms across mental disorders. Accredited Exercise Physiologists (AEPs) are trained to lead PA interventions for people with mental illness, but referrals to AEPs are low. Aims: To determine the knowledge and attitudes of delegates attending the 2017 Royal Australian and New Zealand College of Psychiatrists (RANZCP) conference toward physical health monitoring and exercise interventions for people with mental illness. Methods: A cross-sectional survey of RANZCP delegates investigated knowledge and attitudes toward PA for people with mental illness, self-reported PA, and their understanding of AEP’s role within mental health settings. A subgroup of delegates underwent fitness assessments. Results: Seventy-three delegates completed surveys and 24 underwent fitness assessments. Delegates demonstrated good knowledge regarding associations between PA and cardiovascular disease risk. Delegates were less knowledgeable of AEP’s role within mental health settings. Forty-six participants (63%) did not meet the Australian recommended guidelines for PA. No association between referrals to AEPs and self-reported PA or fitness measures were evident. Conclusions: Promoting PA participation for mental health professionals, coupled with education on the important role AEPs play in the multidisciplinary treatment of mental health consumers is vital to improve health outcomes for this vulnerable group

Self-reported physical activity levels of the 2017 Royal Australian and New Zealand College of Psychiatrists (RANZCP) conference delegates and their exercise referral practices

Stanton, R ORCiD: 0000-0002-6684-5087Background: Physical activity (PA) significantly improves physical health and clinical symptoms across mental disorders. Accredited Exercise Physiologists (AEPs) are trained to lead PA interventions for people with mental illness, but referrals to AEPs are low. Aims: To determine the knowledge and attitudes of delegates attending the 2017 Royal Australian and New Zealand College of Psychiatrists (RANZCP) conference toward physical health monitoring and exercise interventions for people with mental illness. Methods: A cross-sectional survey of RANZCP delegates investigated knowledge and attitudes toward PA for people with mental illness, self-reported PA, and their understanding of AEP’s role within mental health settings. A subgroup of delegates underwent fitness assessments. Results: Seventy-three delegates completed surveys and 24 underwent fitness assessments. Delegates demonstrated good knowledge regarding associations between PA and cardiovascular disease risk. Delegates were less knowledgeable of AEP’s role within mental health settings. Forty-six participants (63%) did not meet the Australian recommended guidelines for PA. No association between referrals to AEPs and self-reported PA or fitness measures were evident. Conclusions: Promoting PA participation for mental health professionals, coupled with education on the important role AEPs play in the multidisciplinary treatment of mental health consumers is vital to improve health outcomes for this vulnerable group. © 2018, © 2018 Informa UK Limited, trading as Taylor & Francis Group